Provider Demographics
NPI:1689236077
Name:GIBSON, COURTNEY SHAE (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:SHAE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:2410 ROUND ROCK AVE STE 150
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4019
Practice Address - Country:US
Practice Address - Phone:512-341-8724
Practice Address - Fax:512-687-0295
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-05
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH092344-23363L00000X
TXAP141935363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX401436703Medicaid
TX401436702Medicaid